MEDICARE: CENTENNIAL MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0014X	Interventional Pain Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V103360	OTHER	NV	MEDICARE P-10

General Provider Information

NPI Number	:	1598926677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTENNIAL MEDICAL GROUP

Provider Business Mailing Address
First Line	:	4454 N DECATUR BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-5286
Country	:	US
Telephone Number	:	702-839-1203
Fax Number	:	702-507-0992

Provider Business Practice Location Address
First Line	:	4640 W CRAIG RD
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-2743
Country	:	US
Telephone Number	:	702-839-1203
Fax Number	:	702-507-0992

Authorized Official
Title or Position	:	OPERATIONS DIRECTOR
Name	:	MRS. CARLA SHERWOOD
Credential	:
Telephone Number	:	702-818-2825

Provider Enumeration Date	:	06/20/2008
Last Update Date	:	06/20/2008

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Directions to “CENTENNIAL MEDICAL GROUP ” Practice Location

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